Provider EDI
Reference Guide
Highmark EDI Operations
April 5, 2010Table of Contents
Chapter 1 • Introduction
13
1.1 Supported EDI Transactions. . . 14
1.2 Real-Time Transaction Capability. . . 15
1.2.1 Real-Time Technical Connectivity Specifications. . . 15
1.2.2 Real-Time Claim Adjudication and Estimation . . . 16
1.2.2.1 General Requirements and Best Practices . . . 16
Chapter 2 • General Information
19
2 Contact Information . . . 192.1 System Operating Hours. . . 20
2.2 Provider Data Services . . . 20
2.3 Audit Procedures . . . 20
2.4 Valid Characters in Text Data (AN, string data element type) . . . 21
Chapter 3 • Security Features
23
3.1 Confidentiality . . . 233.2 Authorized Release of Information . . . 23
Chapter 4 • Authorization Process
25
4.1 Where to Get Enrollment Forms to Request a Trading Partner ID 25 4.2 Receiving 835 Transactions Generated from the Payment Cycle (Batch) . . . 264.3 Adding a New Provider to an Existing Trading Partner. . . 26
Highmark
Table of Contents Provider EDI Reference Guide
4.6 Out of State Providers. . . 26
Chapter 5 • Testing Policy
29
5.1 Web Based . . . 295.2 Highmark Transactional Testing . . . 30
5.2.1 Real-Time 837 Claim Estimation Demonstration Process . . 30
Chapter 6 • Communications
33
6.1 Dial-Up / Asynchronous File Transfer . . . 336.1.1 Dial-Up Command Prompt Option . . . 33
6.2 Internet . . . 34
6.2.1 Internet File Transfer Protocol (FTP) through “eDelivery” . . 34
6.2.2 Internet/Real-Time (HTTPS- Hypertext Terminal Protocol Se-cure) . . . 36
Chapter 7 • Transmission Envelopes
39
7.1 General Information . . . 397.1.1 Delimiters . . . 39
7.2 Data Detail and Explanation of Incoming ISA to Highmark. . . 42
ISA
Interchange Control Header (Incoming). . . 427.3 Data Detail and Explanation of Outgoing ISA from Highmark . . . 43
ISA
Interchange Control Header (Outgoing). . . 437.4 Outgoing Interchange Acknowledgment TA1 Segment . . . 44
7.5 Outgoing Functional Acknowledgment 997 Transaction. . . 45
Chapter 8 • Professional Claim (837P)
47
8.1 General Information and Guidelines for Submitting an 837P . . . . 518.1.1 Patient with Coverage from Another Blue Cross Blue Shield Plan . . . 51
8.1.1.1 KHP Central Out-of-Area Claims . . . 51
8.1.1.2 First Priority Life Insurance Company (FPLIC) Out-of-Area Claims. . . 52
Highmark
Provider EDI Reference Guide Table of Contents
8.1.1.4 Keystone Health Plan East (KHP East) Out-of-Area Claims 52
8.1.2 Dental Services . . . 53
8.1.3 Data that is Not Used . . . 53
8.1.4 Transaction Size. . . 54
8.1.5 Suffix on Highmark’s NAIC Code for Vision Claims . . . 54
8.1.6 Ambulance Claims . . . 55
8.1.7 Provider and Service Facility Location Identification Numbers. 55 8.1.8 Claim Submission Acknowledgment . . . 55
8.1.9 National Provider Identifier (NPI) . . . 56
8.1.10 Balancing . . . 58
8.1.11 Real-Time Claim Adjudication and Estimation . . . 58
8.1.11.1 Real-Time 837 Submission Limitations . . . 59
8.1.11.2 General Requirements and Best Practices . . . 59
8.2 Data Detail for 837P . . . 60
GS
Functional Group Header . . . 61REF
Transmission Type Identification . . . 62NM1
Submitter Name . . . 62NM1
Receiver Name . . . 63PRV
Billing/Pay-to Provider Specialty Information . . . 63N3
Billing Provider Address . . . 63N4
Billing Provider City/State/Zip . . . 64SBR
Subscriber Information. . . 64NM1
Subscriber Name . . . 65NM1
Payer Name . . . 65NM1
Patient Name . . . 66CLM
Claim Information. . . 66DTP
Date - Date Last Seen . . . 67DTP
Date - Admission . . . 67PWK
Claim Supplemental Information. . . 67AMT
Total Purchase Service Amount . . . 69REF
Mammography Certification Number . . . 69CR2
Spinal Manipulation Information . . . 69CRC
Patient Condition Information - Vision . . . 70Highmark
Table of Contents Provider EDI Reference Guide
PRV
Rendering Provider Specialty Information . . . 71NM1
Service Facility Location . . . 71N3
Service Facility Location Address . . . 72N4
Service Facility Location City/State/Zip . . . 72SBR
Other Subscriber Information. . . 73AMT
COB Patient Paid Amount. . . 74NM1
Other Payer Name . . . 75SV1
Service Line . . . 76AMT
Sales Tax Amount . . . 77PS1
Purchase Service Information. . . 77LIN
Drug Identification . . . 77CTP
Drug Pricing . . . 78NM1
Rendering Provider Name . . . 78PRV
Rendering Provider Specialty Information . . . 78REF
Service Facility Location Secondary Identification . . . 79PRV
Referring Provider Specialty Information . . . 79Chapter 9 • Institutional Claim (837I)
81
9.1 General Information and Guidelines for Submitting an 837I . . . 839.1.1 Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan . . . 83
9.1.1.1 KHP Central Out-of-Area Claims (Western Region). . . 83
9.1.2 Data that is Not Used . . . 84
9.1.3 Transaction Size. . . 85
9.1.4 Number of Lines per Claim. . . 85
9.1.5 Suffix on Highmark’s NAIC Code . . . 85
9.1.6 Standalone Major Medical . . . 85
9.1.7 Provider Identification Numbers . . . 86
9.1.8 Claim Submission Acknowledgment . . . 86
9.1.9 National Provider Identifier (NPI) . . . 86
9.1.10 Balancing . . . 88
9.1.11 Real Time Claim Adjudication and Estimation . . . 88
9.1.11.1 Real-Time 837 Submission Limitations . . . 89
9.1.11.2 General Requirements and Best Practices . . . 89
Highmark
Provider EDI Reference Guide Table of Contents
GS
Functional Group Header . . . 90REF
Transmission Type Identification . . . 92NM1
Submitter Name . . . 92NM1
Receiver Name . . . 93PRV
Billing/Pay-To Provider Specialty Information . . . 93N3
Billing Provider Address. . . 93N4
Billing Provider City/State/Zip . . . 94SBR
Subscriber Information. . . 94NM1
Subscriber Name . . . 95NM1
Payer Name . . . 95NM1
Patient Name . . . 96CLM
Claim Information . . . 96DTP
Discharge Hour . . . 97DTP
Admission Date / Hour . . . 97PWK
Claim Supplemental Information. . . 98CN1
Contract Information . . . 99REF
Original Reference Number (ICN/DCN) . . . 99K3
File Information . . . 100HI
Principal Procedure Information . . . 101HI
Other Procedure Information. . . 102HI
Value Information . . . 102NM1
Attending Physician, Operating Physician, and Other Provider Name . . . 103PRV
Attending Physician Specialty Information . . . 104NM1
Service Facility Name . . . 104N3
Service Facility Address . . . 104N4
Service Facility City/State/Zip Code . . . 105SBR
Other Subscriber Information. . . 105NM1
Other Payer Name . . . 106LIN
Drug Identification . . . 106CTP
Drug Pricing . . . 107NM1
Attending Physician, Operating Physician, and Other Provider Name . . . 107Highmark
Table of Contents Provider EDI Reference Guide
Chapter 10 • Claim Acknowledgment (277)
109
10.1 General Information and Guidelines for 277 Claim
Acknowledg-ment. . . 110
10.1.1 Identifying the 837 in the 277 Claim Acknowledgment. . . 110
10.1.2 Front-End Editing: Level Types 1-5 . . . 110
10.1.3 Text Format Options. . . 111
10.1.4 Timeframe for Batch 277 Claim Acknowledgment . . . 112
10.1.5 Specifications . . . 112
10.1.6 Real-Time Claim Acknowledgment . . . 112
10.1.6.1 Claim Adjudication . . . 112
10.1.6.2 Claim Estimation. . . 113
10.1.6.3 General Requirements and Best Practices . . . 113
Chapter 11 • Claim Payment Advice (835)
115
11.1 General Information and Guidelines for 835 . . . 11611.1.1 Missing Checks . . . 116
11.1.2 Administrative Checks . . . 116
11.1.3 Availability of Payment Cycle 835 Transactions (Batch) . 116 11.1.4 Highmark Private Business and Medicare Supplemental. 117 11.1.5 Highmark Major Medical. . . 117
11.1.6 Highmark Oral Surgery. . . 117
11.1.7 Unavailable Claim Data . . . 117
11.1.8 Claim Overpayment Refunds . . . 118
11.1.8.1 Institutional Claims . . . 118
11.1.8.2 Professional Claims . . . 119
11.1.9 Electronic Funds Transfer (EFT) . . . 120
11.1.10 Capitation Payments . . . 120
11.1.11 Member Identification Numbers . . . 120
11.1.12 Data that is Not Used . . . 120
11.1.13 National Provider Identifier (NPI) . . . 121
11.1.14 Provider Payments from Member Health Care Accounts122 11.1.15 Real-Time 835 Response. . . 124
11.1.15.1 Real-Time Response for Claim Adjudication . . . 124
11.1.15.2 Real-Time 835 Response for Claim Estimation . . . 125
11.1.15.3 General Requirements and Best Practices . . . 127
Highmark
Provider EDI Reference Guide Table of Contents
GS
Functional Group Header . . . 129BPR
Financial Information . . . 130REF
Receiver Identification . . . 131REF
Additional Payer Identification . . . 131N1
Payee Identification . . . 132REF
Payee Additional Identification . . . 132LX
Header Number . . . 133CLP
Claim Payment Information . . . 133NM1
Service Provider Name . . . 134REF
Other Claim Related Identification . . . 134SVC
Service Payment Information . . . 135PLB
Provider Adjustment . . . 136Chapter 12 • Claim Status (276 & 277)
139
12.1 General Instructions and Guidelines for 276 and 277. . . 14112.1.1 General Instructions and Guidelines for 276 . . . 141
12.1.1.1 General Description . . . 141
12.1.1.2 Dental Services . . . 141
12.1.1.3 Data that Is Not Used . . . 142
12.1.1.4 Minimum Requirements . . . 142
12.1.1.5 Situational Elements and Data Content . . . 143
12.1.1.6 Requests Per Transaction Mode . . . 143
12.1.1.7 Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan . . . 144
12.1.2 General Instructions and Guidelines for 277 . . . 144
12.1.2.1 General Description of 277 . . . 144
12.1.2.2 Claim Splits. . . 145
12.1.2.3 Customer Service Requests . . . 145
12.1.2.4 Maximum Claim Responses per Subscriber/Patient/Depen-dent. . . 145
12.1.2.5 Corrected Subscriber and Dependent Level . . . 145
12.1.2.6 National Provider Identifier . . . 145
12.2 Data Detail for 276 . . . 146
GS
Functional Group Header . . . 146Highmark
Table of Contents Provider EDI Reference Guide
NM1
Provider Name . . . 148NM1
Subscriber Name . . . 149REF
Payer Claim ID Number . . . 14912.3 Data Detail for Claim Status Response (277) . . . 150
GS
Functional Group Header . . . 150NM1
Provider Name . . . 151REF
Payer Claim Identification Number . . . 151Chapter 13 • Eligibility Request-270 / Response-271
153
13.1 General Instructions and Guidelines for 270 and 271. . . 15413.1.1 Highmark Requirements. . . 154
13.1.2 Dental and Oral Surgery Inquiries . . . 154
13.1.3 Definition of Active Coverage . . . 154
13.1.4 Benefit Inquiries . . . 154
13.1.5 Allowable Time Frames for Inquiries . . . 155
13.1.6 Disclaimers . . . 155
13.1.7 Dates on the Incoming 270. . . 155
13.1.8 Range Dates on the Incoming 270 . . . 155
13.1.9 Level of Detail on Outbound 271 . . . 156
13.1.10 Specific Service Code Request . . . 156
13.1.11 Generic Service Code Request . . . 156
13.1.12 Real-Time Request. . . 156
13.1.13 (Left blank intentionally.). . . 156
13.1.14 Data that is Not Used . . . 156
13.1.15 Requests Per Transaction Mode . . . 157
13.1.16 Date Ranges Submitted on the 270 . . . 158
13.1.17 Minimum Amount of Data Required for Search . . . 158
13.1.18 Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan . . . 158
13.2 270/271 Data Detail Instructions. . . 159
13.2.1 Data Detail for Eligibility Request (270) . . . 159
GS
Functional Group Header . . . 160BHT
Beginning of Hierarchical Transaction . . . 161NM1
Information Source Name . . . 161Highmark
Provider EDI Reference Guide Table of Contents
NM1
Subscriber/Dependent Name. . . 162REF
Subscriber/Dependent Additional Identification . . . 163PRV
Provider Information . . . 163EQ
Subscriber/Dependent Eligibility or Benefit Inquiry Information 164III
Subscriber/Dependent Eligibility or Benefit Inquiry Information . 164 13.2.2 Data Detail for Eligibility Response (271) . . . 165GS
Functional Group Header . . . 165NM1
Information Receiver Name . . . 166NM1
Subscriber/Dependent Name. . . 166N3
Subscriber/Dependent Address. . . 167N4
Subscriber/Dependent City, Street, Zip Code . . . 167DTP
Subscriber/Dependent Date . . . 167REF
Subscriber/Dependent Additional Information . . . 168DTP
Subscriber/Dependent Eligibility/Benefit Date . . . 168MSG
Message Text . . . 168Chapter 14 • Health Care Services Review (278)—Request
and Response
171
14.1 General Information and Guidelines for Submitting a 278 . . . . 17114.1.1 Real-Time Requests. . . 171
14.1.2 Data that is Not Used . . . 172
14.1.3 Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan . . . 172
14.2 Data Detail Instructions. . . 172
14.2.1 Data Detail for Services Review Request (278) . . . 173
GS
Functional Group Header . . . 173NM1
Utilization Management Organization (UMO) Name . . . 174N3
Requester Address . . . 174N4
Requester City/State/Zip Code . . . 175PER
Requester Contact Information . . . 175HI
Subscriber/Dependent Diagnosis . . . 176PWK
Additional Patient Information . . . 176Highmark
Table of Contents Provider EDI Reference Guide
HL
Service Provider Level. . . 178N3
Service Provider Address . . . 179N4
Service Provider City/State/Zip Code . . . 179PER
Service Provider Contact Information . . . 180UM
Health Care Services Review Information . . . 181HI
Procedures . . . 18214.2.2 Data Detail for Services Review Response (278) . . . 183
GS
Functional Group Header . . . 183Appendix A • Highmark Health Insurance Company
185
Appendix B • Medi-CareFirst
BlueCross BlueShield
187
Appendix C • Provider Guide Changes for
Highmark Chapter 1 • Introduction Provider EDI Reference Guide
1 Introduction
The Provider EDI Reference Guide addresses how Providers, or their business associates, conduct Professional Claim, Institutional Claim, Claim Acknowledgment, Claim Payment Advice, Claim Status, Eligibility, and Services Review HIPAA standard electronic transactions with Highmark. This guide also applies to the above referenced transactions that are being transmitted to Highmark by a clearinghouse.
An Electronic Data Interchange (EDI) Trading Partner is defined as any Highmark customer (Provider, Billing Service, Software Vendor, Employer Group, Financial Institution, etc.) that transmits to, or receives electronic data from, Highmark.
Highmark’s EDI transaction system supports transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as well as additional supporting transactions as described in this guide. Highmark EDI Operations supports transactions for multiple payers; each transaction chapter lists the supported payers for that transaction.
While Highmark EDI Operations will accept HIPAA compliant transactions from any covered entity, HIPAA security requirements dictate that proper procedure be established in order to secure access to data. As a result, Highmark has a process in place to establish an Electronic Trading Partner relationship. That process has two aspects: • A Trading Partner Agreement must be submitted which establishes
the legal relationship and requirements. This is separate from a participating provider agreement.
• Once the agreement is received, the Trading Partner will be sent a logon ID and password combination for use when accessing Highmark’s EDI system for submission or retrieval of transactions. This ID is also used within EDI Interchanges as the ID of the Trading Partner. Maintenance of the ID and password by the Trading Partner is detailed in the security section of this document.
Chapter 1 • Introduction Highmark Supported EDI Transactions Provider EDI Reference Guide
1.1
Supported EDI Transactions
Highmark will be supporting the following EDI Transactions:
Provider Transactions
270 Transaction Eligibility/Benefit Inquiry
271 Transaction Eligibility or Benefit Information (response to 270)
276 Transaction Claim Status Request
277 Transaction Claim Status Notification (response to 276)
278 Transaction Two implementations of this transaction: • Services Review — Request for
Review
(Referral/Authorization Request) • Services Review — Response to
Request for Review
837 Transaction Three implementations of this transaction: • Institutional
• Professional • Dental
NOTE: Dental transactions (837Ds) for Highmark products must be sent to Highmark’s dental associate, United Concordia Companies Inc (UCCI). To receive authorization to submit EDI transactions to UCCI, you must contact Dental Electronic Services at
(800) 633-5430.
835 Transaction Claim Payment/Advice (Electronic Remittance)
Highmark Chapter 1 • Introduction Provider EDI Reference Guide Real-Time Transaction Capability
1.2
Real-Time Transaction Capability
Highmark supports all of the EDI transactions listed in Section 1.1 in batch mode. Additionally, Highmark supports all of the Provider Transactions listed in Section 1.1 in real-time mode. The
Acknowledgment Transactions listed in Section 1.1 are also used in real-time mode.
1.2.1
Real-Time Technical Connectivity
Specifications
Highmark maintains separate specifications detailing the technical internet connectivity requirements for Highmark's real-time processes. These connectivity specifications are located in the Resources section under EDI Reference Guides at the following site:
https://www.highmark.com/edi/resources/guides/index.shtml For connectivity specifications related to the Request and Response Inquiry transactions (270/271, 276/277 and 278), see the 'Real-Time Inquiry Connectivity Specifications'.
For connectivity specifications related to Claim Adjudication and Claim Estimation processes (837/835), including a complete
'Transaction Flow' diagram, see the 'Real-Time Claim Adjudication and Estimation Connectivity Specifications'.
Employer/Sponsor Transactions
834 Transaction Benefit Enrollment and Maintenance 820 Transaction Premium Payment
Acknowledgment Transactions TA1 Segment Interchange Acknowledgment
997 Transaction Functional Group Acknowledgment 277 Acknowledgment Claim Acknowledgment to the 837
Chapter 1 • Introduction Highmark Real-Time Transaction Capability Provider EDI Reference Guide
1.2.2
Real-Time Claim Adjudication and
Estimation
Effective November 7, 2008, Highmark implemented real-time
capability for claim adjudication and claim estimation. Both processes leverage the 837 and 835 transactions for these business functions, as well as the 277 Claim Acknowledgment for specific situations.
Real-Time Adjudication - allows providers to submit a claim (837) that is adjudicated in real-time and receive a response (835) at the point of service. This capability allows providers to accurately identify and collect member responsibility based on the finalized claim adjudication results.
Real-Time Estimation - allows providers to submit a claim (837) for a proposed service and receive a response (835) in real-time. The response 835 estimates the member responsibility based on the current point in time and the data submitted for the proposed service. This capability allows providers to identify potential member responsibility and set patient financial expectations prior to a service.
For transaction specific information related to real-time claim adjudication and claim estimation capability, see Chapters:
8 - Professional Claim (837P) 9 - Institutional Claim (837I) 10 - Claim Acknowledgment (277) 11 - Claim Payment Advice (835)
1.2.2.1
General Requirements and Best Practices
Trading Partners must use the ASC X12 National Implementation Guides adopted under the HIPAA Administrative Simplification Electronic Transaction rule and Highmark's EDI Reference guidelines for development of the EDI transactions used in the real-time
processes. These documents may be accessed through Highmark's EDI Trading Partner Portal:
https://www.highmark.com/edi/resources/guides/index.shtml
Trading Partners must use the most current national standard code lists applicable to the EDI transactions. The code lists may be accessed at the Washington Publishing Company website:
Highmark Chapter 1 • Introduction Provider EDI Reference Guide Real-Time Transaction Capability
The applicable code lists and their respective X12 transactions are as follows:
• Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835)
• Claim Status Category Codes and Claim Status Codes (277 Claim Acknowledgement)
Chapter 1 • Introduction Highmark Real-Time Transaction Capability Provider EDI Reference Guide
Highmark Chapter 2 • General Information
Provider EDI Reference Guide Contact Information
2 General Information
EDI specifications, including this reference guide, can be accessed online at: https://www.highmark.com/edi/resources/guides/index.shtml
Contact Information
Contact information for EDI Operations: Address: EDI Operations
P.O. Box 890089
Camp Hill, PA 17089-0089 or
TELEPHONE NUMBER: (717) 302-5170 or (800) 992-0246
EMAIL ADDRESS: [email protected]
When contacting EDI Operations have your Trading Partner Number and Logon ID available. These numbers facilitate the handling of your questions.
Inquiries pertaining to Highmark Private Business Medical/Surgical or Dental claims should be directed to the appropriate Customer Service Department listed below:
Central Region (866) 731-8080
Western Region (866) 975-5054
Eastern Region (866) 975-7290
FEP (866) 763-3608
Dental (Commercial Products) (800) 332-0366 Dental (TriCare Dental Programs) (800) 866-8499
Clarity Vision (717) 302-5103
Chapter 2 • General Information Highmark
System Operating Hours Provider EDI Reference Guide
EDI Operations personnel are available for questions from 8:00 a.m. to 5:00 p.m. ET, Monday through Friday.
2.1
System Operating Hours
Highmark is available to handle EDI transactions 24 hours a day seven days a week, except during scheduled system maintenance periods. We strongly suggest that Highmark EDI Trading Partners transmit any test data during the hours that Highmark EDI Operations support is available.
2.2
Provider Data Services
To obtain the status of a provider’s application for participation with any Highmark provider network, please contact Provider Data Services at (866) 763-3224 (option 6). Also, use this number to update provider data currently on file with Highmark. Note that this number only serves Highmark networks; provider data for other payers mentioned in this guide for EDI transactions must be communicated as established by those other payers.
2.3
Audit Procedures
The Trading Partner ensures that input documents and medical records are available for every automated claim for audit purposes. Highmark may require access to the records at any time.
The Trading Partner’s automated claim input documents must be kept on file for a period of seven years after date of service for auditing purposes. Microfilm/microfiche copies of Trading Partner documents are acceptable. The Trading Partner, not his billing agent, is held accountable for accurate records.
The audit consists of verifying a sample of automated claim input against medical records. Retention of records may also be checked. Compliance to reporting requirements is sample checked to ensure proper coding technique is employed. Signature on file records may also be verified.
In accordance with the Trading Partner Agreement, Highmark may request, and the Trading Partner is obligated to provide, access to the records at any time.
Highmark Chapter 2 • General Information Provider EDI Reference Guide Valid Characters in Text Data (AN, string data element type)
2.4
Valid Characters in Text Data (AN, string
data element type)
For data elements that are type AN, "string", Highmark can accept characters from the basic and extended character sets with the following exceptions:
Character Name Hex value
! Exclamation point (21)
> Greater than (3E)
^ Caret (5E)
| Pipe (7C)
~ Tilde (7E)
These five characters are used by Highmark for delimiters on outgoing transactions and control characters for internal processing and therefore would cause problems if encountered in the transaction data. As described in the X12 standards organization's Application Control Structure document (X12.6), a string data element is a sequence of characters from the basic or extended character sets and contains at least one non-space character. The significant characters shall be left justified. Leading spaces, when they occur, are presumed to be significant characters. In the actual data stream trailing spaces should be suppressed. The representation for this data element type is AN.
Chapter 2 • General Information Highmark Valid Characters in Text Data (AN, string data element type) Provider EDI Reference Guide
Highmark Chapter 3 • Security Features
Provider EDI Reference Guide Confidentiality
3 Security Features
Highmark EDI Operations personnel will assign Logon IDs and Passwords to Trading Partners. EDI Transactions submitted by unauthorized Trading Partners will not be accepted by our Highmark EDI Operations system.
Trading Partners should protect password privacy by limiting knowledge of the password to key personnel. Passwords should be changed regularly; upon initial usage and then periodically throughout the year. Also, the password should be changed if there are personnel changes in the Trading Partner office, or at any time the Trading Partner deems necessary.
Password requirements include:
• Password must be 8 characters in length.
• Password must contain a combination of both numeric and alpha characters.
• Password cannot contain the Logon ID. • Password must be changed periodically.
3.1
Confidentiality
Highmark and its Trading Partners will comply with the privacy standards for all EDI transactions as outlined in the Highmark EDI Trading Partner Agreement.
3.2
Authorized Release of Information
When contacting EDI Operations concerning any EDI transactions, you will be asked to confirm your Trading Partner information.
Chapter 3 • Security Features Highmark Authorized Release of Information Provider EDI Reference Guide
Highmark Chapter 4 • Authorization Process Provider EDI Reference Guide Where to Get Enrollment Forms to Request a Trading Partner ID
4 Authorization Process
New Trading Partners wishing to submit EDI transactions must submit an EDI Transaction Application to Highmark EDI Operations.
The EDI Transaction Application process includes review and acceptance of the appropriate EDI Trading Partner Agreement. Submission of the EDI Transaction Application indicates compliance with specifications set forth by Highmark for the submission of EDI transactions. This form must be completed by an authorized
representative of the organization.
Highmark may terminate this Agreement, without notice, if participant’s account is inactive for a period of six (6) consecutive months.
Complete and accurate reporting of information will insure that your authorization forms are processed in a timely manner. If you need assistance in completing the EDI Transaction Application contact your company’s technical support area, your software vendor, or EDI Operations.
Upon completion of the authorization process, a Logon ID and
Password will be assigned to the Trading Partner. EDI Operations will authorize, in writing, the Trading Partner to submit production EDI transactions.
Test files may be submitted at the discretion of the Trading Partner.
4.1
Where to Get Enrollment Forms to
Request a Trading Partner ID
To receive a Trading Partner ID, you must complete an online EDI Transaction Application and agree to the terms of Highmark's EDI Trading Partner Agreement. The EDI Transaction Applications and all other EDI request forms are available through the Enrollment Center on our Internet website. You may access the online Application from the page accessed by the link below.
Resource Center
Chapter 4 • Authorization Process Highmark Receiving 835 Transactions Generated from the Payment Cycle (Batch) Provider EDI Reference Guide
4.2
Receiving 835 Transactions Generated
from the Payment Cycle (Batch)
If you are not currently receiving 835 remittance transactions generated from the payment cycle in a batch process and wish to, you will need to complete a new EDI Transaction Application and choose the "Upgrade and Existing Trading Partner" option.
4.3
Adding a New Provider to an Existing
Trading Partner
Trading Partners currently using electronic claim submission who wish to add a new provider to their Trading Partner Number should complete an EDI Transaction Application and select the option to "Add a
provider to an existing Trading Partner".
4.4
Deleting Providers from an Existing
Trading Partner
Providers wishing to be deleted from an existing Trading Partner should complete an EDI Transaction Application and select the option for "Removal of Trading Partner or Provider.
4.5
Reporting Changes in Status
Trading Partners changing their information must inform EDI Operations by completing an EDI Transaction Application and including all information that is to be updated.
Resource Center
https://www.highmark.com/edi/signup/index.shtml
4.6
Out of State Providers
Due to an operating arrangement among Plans that are licensees of the Blue Cross Blue Shield Association, Highmark cannot accept
electronic transactions from out of state nonparticipating/out-of-network providers for Highmark members. Providers should submit all Blue Cross Blue Shield electronic claims and inquiry transactions to their local Blue Cross Blue Shield Plan. The transactions will be sent
Highmark Chapter 4 • Authorization Process
Provider EDI Reference Guide Out of State Providers
on to the Plan that holds the member's enrollment, for processing through the BlueCard or BlueExchange programs.
Mountain State providers submitting transactions for Highmark Health Insurance Company (HHIC) members should refer to the Mountain State Blue Cross Blue Shield's Provider EDI Guide (https://
www.msbcbs.com/PDFFiles/Provider-EDI-Guide.pdf) for instructions. For Medi-CareFirst Members, see Appendix B.
Chapter 4 • Authorization Process Highmark
Highmark Chapter 5 • Testing Policy
Provider EDI Reference Guide Web Based
5 Testing Policy
Highmark offers two levels of testing to potential trading partners. These levels are described below along with start-up instructions and contacts.
5.1
Web Based
The first level is Web-based syntax and validation testing using a Highmark-customized version of Foresight Corporation’s HIPAA Validator product. Web-based testing is available for claims where the Interchange Receiver ID (ISA08) is Highmark (54771). Web-based testing is also available for 270 Eligibility, 276 Claim Status, 278 Service Review, 820 Premium Payment, and 834 Enrollment transactions where the payer is Highmark. This testing includes the following types of edits:
• Transaction syntax testing (4010 transaction standards), • HIPAA data requirements testing (4010A1 Addenda
Implementation Guides),
• Front-end acceptance (payer) business rules.
This Web-based testing is available free of charge to our trading partners who have executed a new EDI Trading Partner Agreement. This functionality is designed to make EDI HIPAA syntax and validation testing for Highmark fast, simple, and secure by using a Web-based environment. Testing partners will receive detailed error analysis reports or a notice of successful validation. For more information on Foresight’s Validator™, please visit their Web site describing the product at http://foresightcorp.com.
If you need assistance during your Validator™ testing, you may call EDI Operations at 800-992-0246 or e-mail us at
[email protected]. A member of our support staff will be available Monday through Friday 8:00 a.m. to 5:00 p.m. ET to assist with any HIPAA Validator™ Trading Partner Testing questions you may have.
To get started, you need a Highmark Trading Partner ID. This requires completion of an EDI Transaction Application and execution of an EDI Trading Partner Agreement as explained in section 4.1. The
Chapter 5 • Testing Policy Highmark Highmark Transactional Testing Provider EDI Reference Guide Transaction Application includes a place to request access to the Web-based testing function.
5.2
Highmark Transactional Testing
The second level involves connecting to Highmark and submitting a transaction file. Transactions will be taken into Highmark’s translator and edited for X12 syntax. For all batch transactions, a functional acknowledgment 997 transaction will be returned indicating the results of the test. For real-time test transactions, a functional acknowledgment 997 will only be returned if a rejection occurs at this level of editing. Note that syntax checking is done for any transaction submitted to Highmark regardless of test or production status of the submitted file. When the test transaction is an inquiry type request and response transaction (270/271, 276/277) which does not impact/update the adjudication system, the response will be based on data found in the adjudication system.
When testing the batch 837 claim transaction for adjudication, a generic response 277 Claim Acknowledgment (277CA) will be placed in the trading partner's mailbox for retrieval after a successful test. The data contained in the generic 277CA is "canned" and not related to the actual file submitted. Testing for a real-time 837 transaction for claim adjudication cannot be performed due to the potential adjudication system impact or updating. See Section 5.2.1 Highmark Real-Time 837 Estimation Demonstration Process for information on the testing process for a real-time 837 transaction.
NOTE: Highmark is using a 277 Claim Acknowledgment for
individual claim responses to an 837 submission. Refer to Chapter 10 - Claim Acknowledgment (277) for additional information on
Highmark's implementation of this transaction.
Trading Partners may choose to submit test transactions to Highmark at any time. In order to submit a test file, you must indicate “test” in the ISA segment. Any transactions marked as “production” will be processed against actual production data.
5.2.1
Real-Time 837 Claim Estimation
Demonstration Process
Highmark's real-time 837 Estimation process does not impact or actually update the claim adjudication system with respect to a patient's claim history, accumulated member liability, maximums, etc.
Highmark Chapter 5 • Testing Policy Provider EDI Reference Guide Highmark Transactional Testing
to test real-time 837 capabilities will have to do so using the 837 Estimation process.
Professional and Institutional Trading Partners have the ability to validate their secure Internet connection to Highmark, as well as submit an 837 Estimation which will be edited for X12 syntax and Highmark business edits. If the 837 Estimation passes the edits, member liability will be estimated with the end results being returned in a real-time 835 response.
• A functional acknowledgment 997 transaction will be returned in the event that a rejection occurs at the X12 syntax editing level. • A 277CA transaction will be returned in the event that a rejection
occurs as a result of Highmark business editing. The 277CA transaction will return actual editing results
• If the 837 Estimation transaction passes the X12 syntax and
Highmark business level edits, a real-time 835 response containing the member's estimated liability and provider's estimated payment will be returned.
• In the event the 837 Estimation cannot be finalized within the real-time process, an accepted 277CA will be returned indicating the 'Estimation cannot be completed in real-time'.
In order to submit a real-time 837 Estimation test transaction, the ISA15 value must be equal to a "T". For more information on HTTPS connectivity specifications for demonstration of 837 Estimation submissions, refer to the Real-Time Claim Adjudication and Estimation Connectivity Specifications. These connectivity specifications are located in the Resources section under EDI Reference Guides at the following site:
Chapter 5 • Testing Policy Highmark Highmark Transactional Testing Provider EDI Reference Guide
Highmark Chapter 6 • Communications Provider EDI Reference Guide Dial-Up / Asynchronous File Transfer
6 Communications
Highmark offers its Trading Partners three types of communication methods for transferring data electronically.
• Dial-up (modem-to-modem) is available for transactions in batch mode.
• File Transfer Protocol (FTP) through a secure Internet connection (eDelivery) is available for transactions in batch mode.
• Hypertext Terminal Protocol Secure (HTTPS) through an Internet web service is available for transactions in real-time mode.
6.1
Dial-Up / Asynchronous File Transfer
Trading Partners submitting via modem dial a telephone number and establish a reliable link with Highmark. In order to submit
electronically via modem, you will need a computer, modem, and software programmed with the option to submit electronically to Highmark. Additionally, a dedicated telephone line for your modem is recommended. Trading Partners should use modems that support the Z modem transfer protocol and incorporate error correction capabilities. Modem baud rates can range up to 56,000.
For transmitting or retrieving transactions, the asynchronous phone numbers are (877) 533-1359 (Toll-Free) and (717) 214-7376 (Toll).
You must use the Toll number when retrieving 835 transactions. After connecting to Highmark, you will be required to enter your EDI User Logon ID.
6.1.1
Dial-Up Command Prompt Option
To reach a command prompt, enter the Logon ID followed by a
semicolon(;). You will then be required to enter your password. At that point, you will get to the prompt (PN>). The alpha character in the Logon ID must be entered in lower case. The following is a list of valid commands that can be entered at the prompt.
Note: All of the commands are shown here in upper case. These commands must be entered into the system in lower case (no shift key or shift-lock). The system will always echo the characters back in upper
Chapter 6 • Communications Highmark
Internet Provider EDI Reference Guide
XS Submit any X12 transaction
XACK Retrieve any and all X12 functional acknowledgments XR Retrieve 835 transactions
X271 Retrieve 271 transactions (response to 270 inquiry) X277 Retrieve 277 transactions
X277U Retrieve 277 Claim Acknowledgment transactions (unsolicited)
X278 Retrieve 278 transactions
X### Retrieve other X12 response transactions (future) 5001 Acquire Claim Acknowledgment Report (text
format)
See Section 10 - Claim Acknowledgment for more information on this report.
CHPASS Change Password
L Logoff
6.2
Internet
Highmark offers two methods to utilize the Internet for conducting electronic business with Highmark. The first is secured File Transfer Protocol (FTP) through “eDelivery.” “eDelivery” is available for Trading Partners who submit or receive any HIPAA-compliant EDI transactions in batch mode. The second Internet-based service offers “Real-Time” capability for the following real-time enabled
transactions:
• Eligibility Request/Response - 270/271 • Claim Status Request/Response - 276/277
• Health Care Services Review Request/Response - 278/278 • Claim Adjudication or Estimation and Response - 837/835
6.2.1
Internet File Transfer Protocol (FTP) through
“eDelivery”
The Highmark Secure FTP Server (“eDelivery”) provides an FTP service over an encrypted data session providing “on-the-wire” privacy during file exchanges. This service offers an Internet accessible
Highmark Chapter 6 • Communications
Provider EDI Reference Guide Internet
providers, and business partners using a simple FTP process in an encrypted and private manner.
Any state of the art browser can be used to access the Highmark Secure FTP Server. Browsers must support strong encryption (128 bit) and must allow cookies for session tracking purposes. Once the browser capabilities are confirmed, the following are the general guidelines for exchanging files.
1. Launch your web browser. Highmark has tested Internet Explorer 6.x and Netscape 7.x browsers.
2. Connect to the FTP servers at: https://ftp.highmark.com 3. The server will prompt for an ID and Password. Use the ID/
Password that Highmark has provided you for accessing this service. Enter the ID, tab to password field and enter the password, then hit enter or click on OK.
4. The server will then place you in your individual file space on the FTP server. No one else can see your space and you cannot access the space of others. You will not be able to change out of your space.
5. You will need to change into the directory for the type of file you are putting or getting from the server.
6. By default, the file transfer mode will be binary and this mode is acceptable for all data types. However, you may change between ASCII and Binary file transfer modes by clicking the “Set ASCII”/ ”Set Binary” toggle button.
7. Send Highmark a file. The following is an example of the submission of an 837 claim transaction file:
a. Click on the “hipaa-in” folder to change into that directory. b. Click on the browse button to select a file from your system to
send to Highmark. This will pop open a file finder box listing the files available on your system.
c. Select the file you wish to send to Highmark and Click on OK. d. This will return you to the browser with the file name you
selected in the filename window. Now click on the “Upload File” button to transfer the file to Highmark. Once completed, the file will appear in your file list.
8. Retrieve a file from Highmark. The following is an example of retrieval of a 997 Functional Acknowledgment file:
Chapter 6 • Communications Highmark
Internet Provider EDI Reference Guide
b. Your browser will list all the files available to you. c. Click on the “997” directory.
d. Click on the file you wish to download. Your browser will download the file. If your browser displays the file instead of downloading, click the browser back button and click on the tools next to the file you wish to receive. Select application/ octet-stream. Your system may then prompt you for a “Save As” file location window. Make the selection appropriate for your system and click on Save to download the file.
6.2.2
Internet/Real-Time (HTTPS- Hypertext
Terminal Protocol Secure)
Highmark offers a Real-Time Web Service through a secure Internet connection (HTTPS) for our real-time enabled transactions:
• Eligibility Request/Response - 270/271 • Claim Status Request/Response - 276/277
• Health Care Services Review Request/Response - 278/278 • Claim Adjudication or Estimation and Response - 837/835
Real-time transactions utilize Simple Object Access Protocol (SOAP). SOAP is a way for a program running in one kind of operating system to communicate with another operating system by using Extensible Markup Language (XML) for the exchange of information over the Internet. Since the Internet is being utilized to transport the data, encryption will be utilized to secure messages.
This Real-Time Web Service is designed to support interoperable machine-to-machine interaction over the Internet. In order to submit real-time transactions you will need a computer, a web server, Internet access and the ability to submit and receive HIPAA-compliant
transactions using SOAP.
In order to take advantage of real-time transactions with Highmark, a Trading Partner will need to:
• Check with your EDI software vendor to ensure that the EDI transaction software is programmed for Highmark’s real-time/ SOAP transactions. For instructions on how to program for Highmark's real-time transactions, refer to the "Real-Time Inquiry Connectivity Specifications" or "Real-Time Claim Adjudication and Estimation Connectivity Specifications" in the Resources section under EDI Reference Guides at the following site:
Highmark Chapter 6 • Communications
Provider EDI Reference Guide Internet
https://www.highmark.com/edi/resources/guides/index.shtml • Complete an EDI Transaction Application
o Select the real-time transaction option. o Include your email address.
o Trading Partner must have a valid Internet enabled ‘V’ Logon ID. Real-time can be used with any existing ‘V’ Logon ID.
• Download the Web Services Security Certificate as outlined in appropriate Real-Time Connectivity Specification documents. Real-time transactions are designed to respond to individual end-user requests for real-time enabled transactions.
Inquiry Transactions
For typical inquiry requests, the average response time should be within 15 seconds. Actual response time will be dependent upon real-time transaction activity. Batched inquiries should not be submitted through the real-time process as it may impact the response time.
Claim Adjudication or Estimation Transactions
Real-time claim adjudication or estimation transactions are designed to provide real-time processing and report the results via an 835 response. For typical claim requests, the average response time should be within 30 seconds. Actual response time will be dependent upon real-time transaction activity. Batched claim transmissions should not be submitted through the real-time process as they will receive a rejected 997.
Chapter 6 • Communications Highmark
Highmark Chapter 7 • Transmission Envelopes
Provider EDI Reference Guide General Information
7 Transmission Envelopes
7.1
General Information
Interchange Control (ISA/IEA) and Function Group (GS/GE) envelopes must be used as described in the national implementation guides. Highmark’s expectations for inbound ISAs and a description of data on outbound ISAs are detailed in this chapter. Specific guidelines and instructions for GS and GE segments are contained in each
transaction chapter.
Note - Highmark only supports one interchange (ISA/IEA envelope) per incoming transmission (file). A file containing multiple
interchanges will be rejected for a mismatch between the ISA Interchange Control Number at the top of the file and the IEA Interchange Control Number at the end of the file.
7.1.1
Delimiters
As detailed in the national implementation guides, delimiters are determined by the characters sent in specified, set positions of the ISA header. For transmissions to Highmark EDI Operations (inbound transmissions), the following list contains all characters that can be accepted as a delimiter. Note that LineFeed, hex value “0A”, is not an acceptable delimiter.
Description Hex value
StartOfHeading 01 StartofTeXt 02 EndofTeXt 03 EndOfTrans. 04 ENQuiry 05 ACKnowledge 06 BELL 07 VerticalTab 0B
Chapter 7 • Transmission Envelopes Highmark
General Information Provider EDI Reference Guide
FormFeed 0C CarriageReturn 0D DeviceControl1 11 DeviceControl2 12 DeviceControl3 13 DeviceControl4 14 NegativeAcK 15 SYNchron.Idle 16 EndTransBlock 17 FileSeparator 1C GroupSeparator 1D RecordSeparator 1E ! 21 “ 22 % 25 & 26 ‘ 27 ( 28 ) 29 * 2A + 2B , 2C . 2E / 2F : 3A ; 3B < 3C = 3D
Highmark Chapter 7 • Transmission Envelopes
Provider EDI Reference Guide General Information
* “^” may be used as a Data Element Separator, but will not be accepted as Component Element Separator, Repeating Element Separator, or Segment Terminator.
Highmark will use the following delimiters in all outbound
transactions. Note that these characters as well as the Exclamation Point, "!", can not be used in text data (type AN, Sting data element) within the transaction; reference section 2.5 of this document titled Valid Characters in Text Data.
> 3E ? 3F @ 40 [ 5B ] 5D ^ * 5E { 7B } 7D ~ 7E
Description Hex value
Delimiter Type Character Used (hex value)
Data element separator ^ (5E)
Component element separator > (3E)
Segment terminator ~ (7E)
Repeating element separator (version 4030 and beyond)
Chapter 7 • Transmission Envelopes Highmark Data Detail and Explanation of Incoming ISA to Highmark Provider EDI Reference Guide
7.2
Data Detail and Explanation of Incoming
ISA to Highmark
Segment:
ISA
Interchange Control Header (Incoming)Note: This fixed record length segment must be used in accordance with the guidelines in Appendix B of the national transaction implementation guides, with the clarifications listed below.
Data Element Summary
Ref Des. Element Name Element Note ISA01 Authorization
Information Qualifier
Highmark can only support code 00 - No Authorization Information present.
ISA02 Authorization Information
This element must be space filled.
ISA03 Security Information Qualifier
Highmark can only support code 00 - No security Information present.
ISA04 Security Information
This element must be space filled.
ISA05 Interchange ID Qualifier
Use qualifier code value "ZZ" Mutually Defined to designate a payer-defined ID.
ISA06 Interchange Sender ID
Use the Highmark assigned security Logon ID. The ID must be left justified and space filled. Any alpha characters must be upper case.
ISA07 Interchange ID Qualifier
Use qualifier code value “33”. Highmark only supports the NAIC code to identify the receiver (Highmark).
ISA08 Interchange Receiver ID
Highmark, designated by NAIC code of 54771, must be identified as the Interchange Receiver except for specific situations defined in the 837P and 276/277 transaction portions of this Reference Guide where Independence Blue Cross, designated by NAIC code 54704, is identified as the Interchange Receiver.
Highmark Chapter 7 • Transmission Envelopes Provider EDI Reference Guide Data Detail and Explanation of Outgoing ISA from Highmark
7.3
Data Detail and Explanation of Outgoing
ISA from Highmark
Segment:
ISA
Interchange Control Header (Outgoing)Note: Listed below are clarifications of Highmark’s use of the ISA segment for outgoing interchanges.
ISA14 Acknowledgment Requested
Highmark does not consider the contents of ISA14. A TA1 segment is returned when the incoming interchange is rejected.
ISA15 Usage Indicator Highmark uses the value in this element to determine the test or production nature of all transactions within the interchange.
Data Element Summary
Ref Des. Element Name Element Note
Data Element Summary
Ref Des. Element Name Element Note ISA01 Authorization
Information Qualifier
Highmark can only support code 00 - No Authorization Information present.
ISA02 Authorization Information
This element must be space filled.
ISA03 Security Information Qualifier
Highmark can only support code 00 - No security Information present.
ISA04 Security Information
This element must be space filled.
Chapter 7 • Transmission Envelopes Highmark Outgoing Interchange Acknowledgment TA1 Segment Provider EDI Reference Guide
7.4
Outgoing Interchange Acknowledgment
TA1 Segment
Highmark returns a TA1 Interchange Acknowledgment segment in both batch and real-time modes when the entire interchange (ISA - IEA) must be rejected. TA1 segments are not returned for interchanges that do not have interchange-level errors.
The interchange rejection reason is indicated by the code value in the TA105 data element. This fixed length segment is built in accordance with the guidelines in Appendix B of the national transaction
implementation guides. Each Highmark TA1 will have an Interchange control envelope (ISA - IEA).
ISA06 Interchange Sender ID
Highmark EDI Operations, designated by Highmark's NAIC code of 54771, will be identified as the Interchange Sender except for specific situations defined in the 835 and 276/277 transaction portions of this Reference Guide where Independence Blue Cross, designated by NAIC code 54704, will be identified as the Interchange Sender. • Medi-CareFirst transactions, see Appendix B.
ISA07 Interchange ID Qualifier
Highmark will send qualifier code value “ZZ” Mutually Defined, to designate that a Highmark-assigned
proprietary ID is used to identify the receiver. ISA08 Interchange
Receiver ID
The Highmark-assigned ID will be the trading partner's security logon ID. This ID will be left-justified and space filled.
ISA14 Acknowledgment Requested
Highmark always uses a 0 (No Interchange Acknowledgment Requested).
ISA15 Usage Indicator Highmark provides T or P as appropriate to identify the test or production nature of all transactions within the interchange.
Data Element Summary
Highmark Chapter 7 • Transmission Envelopes Provider EDI Reference Guide Outgoing Functional Acknowledgment 997 Transaction
7.5
Outgoing Functional Acknowledgment
997 Transaction
Highmark returns a 997 Functional Acknowledgment for each
Functional Group (GS - GE) envelope that is received in a batch mode. In real-time mode, a rejected 997 is returned only when the applicable real-time response transaction can not be returned due to rejections at this level. If multiple Functional Groups are received in an Interchange (ISA - IEA) envelope, a corresponding number of 997 Functional Acknowledgment transactions will be returned.
Action on a Functional Group can be: acceptance, partial acceptance, or rejection. A partial acceptance occurs when the Functional Group contains multiple transactions and at least one, but not all, of those transactions is rejected. (Transaction accepted/rejected status is indicated in AK501.) The location and reason for errors are identified in one or more of the following segments:
AK3 - segment errors AK4 - data element errors AK5 - transaction errors AK9 - functional group errors
Rejection reason codes are contained in Appendix B of each
transaction's national Implementation Guide. Rejected transactions or functional groups must be fixed and resubmitted.
997 transactions will have Interchange Control (ISA - IEA) and Functional Group (GS - GE) envelopes. The Version Identifier Code in GS08 of the envelope containing the 997 will be "004010", indicating a generic 4010 997 transaction. Note that this will not match the
Implementation Guide identifier that was in the GS08 of the envelope of the original submitted transaction. This difference is because the 997 is generic to the 4010 version and is not unique to each transaction standard.
As part of your trading partner agreement, values were supplied that identify you as the submitting entity. If any of the values supplied within the envelopes of the submitted transaction do not match the values supplied in the trading partner agreement, a rejected 997 will be returned to the submitter. In the following example the AK404 value ‘TRADING PARTNER PROFILE’ indicates that one or more incorrect values were submitted. In order to process your submission, these values must be corrected and the transaction resubmitted.
Chapter 7 • Transmission Envelopes Highmark Outgoing Functional Acknowledgment 997 Transaction Provider EDI Reference Guide
ISA^00^ ^00^ ^33^54771 ^ZZ^XXXXXXX ^060926^1429^U^00401^035738627^0^P^> GS^FA^XXXXX^999999^20060926^142948^1^X^004010 ST^997^0001 AK1^HC^655 AK2^837^PA03 AK3^GS^114^^8
AK4^2^^7^TRADING PARTNER PROFILE AK5^R
AK9^R^1^1^0 SE^8^0001 GE^1^1
IEA^1^035738627
Highmark systems apply additional editing on the following inbound transactions: 270 Eligibility Inquiry, 276 Claim Status Inquiry, and 278 Referral / Authorization Request. This additional editing results in rejections that will be returned via the 997 response rather than the current 271, 277, or 278 paired response transactions. The advantage to the trading partner is the ability to make corrections to the inbound files immediately without waiting for the paired transaction outbound responses. These edits include:
• Integrity testing - segment validity, segment sequence, element attributes, X12 syntax and rules.
• Requirement testing - national HIPAA implementation guide situational requirements and usage.
• Situation testing - inter-segment dependencies described in the national HIPAA implementation guides.
Highmark Chapter 8 • Professional Claim (837P) Provider EDI Reference Guide
8 Professional Claim (837P)
The 837 transaction is utilized for professional claims and encounters. The May 2000 ASC X12N Implementation Guide named in the HIPAA Administrative Simplification Electronic Transaction rule as modified by the October 2002 Addenda document named in the Modifications to Electronic Data Transaction Standards and Code Sets rule is the primary source for definitions, data usage, and requirements. Companion documents supplement the national guide and addenda with clarifications and payer-specific usage and content requirements. Sections 8.1 and 8.2 of this Reference Guide make up the companion document for submitting 837 Professional claims for patients with Highmark, Federal Employees Health Benefit Plan, Independence Blue Cross / Highmark joint products, BlueCard Par Point of Service (POS), and Highmark Health Insurance Company (HHIC) and Gateway Vision coverage.
Accurate reporting of NAIC codes to identify the appropriate payer and to control routing is critical for claims submitted to Highmark EDI. The 837P Payer ID Chart immediately following this section contains detailed guidelines for submission of the appropriate NAIC code in each of the following 4 data elements:
• Interchange Receiver ID, ISA08 (always 54771 for these benefit programs)
• Application Receiver, GS03 (54771 or 54771V)
• Receiver ID (1000B NM109) in the 837 transaction (always 54771 for these benefit programs)
• Payer ID (2010BB NM109) in the 837 transaction (54771 or 54771V)
Additional Payers
Medi-CareFirst, see Appendix B.
Highmark will accept Independence Blue Cross EDI with 837P transactions for the following additional payers. See the Independence Blue Cross EDI chart in this section for specific coding instructions. • Independence Blue Cross - 54704
Chapter 8 • Professional Claim (837P) Highmark Provider EDI Reference Guide • AmeriHealth NJ & DE HMO - 95044
• AmeriHealth NJ & DE non-HMO - 60061 & 93688 • AmeriHealth Administrators - 54763
• Independence Administrators - 54763 (or TA720)
Claims for the Additional Payers listed above must be submitted in a separate interchange with an ISA08 Interchange Receiver ID of 54704. Required usage of NAIC codes in the GS03 Application Receiver is shown on the second page of the 837P Payer ID Chart.
Highmark Chapter 8 • Professional Claim (837P) Provider EDI Reference Guide
837P Payer ID Chart Send to Highmark EDI
(ISA08 Interchange Receiver ID and 837 Transaction Loop 1000B NM109 Receiver ID = 54771)
Product Member ID Alpha Prefix
PAYER
Loop 2010BB NM109 Payer ID
(GS03 Application Receiver MUST match Payer ID) Highmark
Indemnity, CMM, MM, HMO, PPO, POS (except Personal Choice Network providers), Medicare Supplemental, Federal Employees Health Benefit Plan, Vision.
Various prefixes; "R" for FEHBP; or none.
54771
(54771V for Clarity and Gateway Vision) Independence Blue Cross / Highmark Blue Shield Joint
Products
QCD, QCP, QCS, QCT, QCW, YDX
54771
BlueCard Par Point of Service (POS) AMS, ATS, NJP, YHF
54771
BlueCard Par Point of Service (POS)
Alpha prefix UPP with Plan Code 362, 363, 378, or blank suitcase
UPP 54771
Independence Blue Cross alpha prefix codes are not valid on a claim submitted to Highmark EDI (Receiver ID 54771), unless a vision claim (Receiver ID 54771V).
Chapter 8 • Professional Claim (837P) Highmark Provider EDI Reference Guide
Independence Blue Cross EDI;
Separate File with ISA08 Interchange Receiver ID = 54704
Product GS03 Application
Receiver
TRANSACTION
Loop 1000B NM109 Receiver ID, and
Loop 2010BB NM109 Payer ID
Independence Blue Cross - Blue Choice
- Personal Choice - Personal Choice 65
- All POS Products for Personal Choice Network Providers
54704 See IBC Companion Document
Keystone Health Plan East 95056 See KHP East Companion Document. Providers in the IBC Area.*
AmeriHealth NJ, DE, & PA HMO
95044 See AmeriHealth Companion Document
AmeriHealth NJ PPO / CMM
60061 See AmeriHealth Companion Document
AmeriHealth DE PPO
93688 See AmeriHealth Companion Document
AmeriHealth Administrators (AHA) 54763 See AHA Companion Document Independence Administrators (IA)
All providers in IBC service area*, and Personal Choice Network Providers outside IBC service area*.
TA720 or 54763
See IA Companion Document
* IBC service area includes the following counties: Philadelphia, Bucks, Chester, Delaware and Montgomery.
ALPHA PREFIX LINKS:
The following links provide all of the alpha prefixes associated with IBC and AmeriHealth products:
http://www.ibx.com/pdfs/providers/claims_and_billing/edi/ibc_professional_payer_id.pdf IBC Payer ID Provider Number Reference
AmeriHealth Payer ID Provider Number Reference
